Diffuse Large B-Cell Lymphoma in the Elderly: Real World Outcomes of Immunochemotherapy in Asian Population

Diffuse Large B-Cell Lymphoma Treated With R-CHOP in a Resource-Limited Setting in South Africa: A Real-World Study

BACKGROUND

Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin's lymphoma worldwide and particularly in Africa, where the incidence of HIV is the highest in the world. R-CHOP is the standard of care regimen for DLBCL, but access to rituximab is limited in developing countries.

METHODS

This is a retrospective cohort study that included all HIV-negative patients with DLBCL who received R-CHOP at a single institution from January 2012 to December 2017. Clinical and demographic data were collected to assess factors that influenced survival.

RESULTS

Seventy-three patients were included. Median age was 55 (17-76), 67.1% of patients were younger than 60 years, and 60.3% were female. Most presented with stages III/IV disease (53.5%) but with good performance status (56.% PS 0 and 1). Progression-free survival at 3 and 5 years was 75% and 69%, and overall survival at 3 and 5 years was 77% and 74%, respectively. Median survival had not been reached with a median follow-up of 3.5 years(0.13-7.9). Overall survival was significantly affected by performance status (P = .04), but not by IPI or age. Survival was significantly associated with response to chemotherapy after 4-5 cycles of R-CHOP (P = 0.005).

CONCLUSIONS

Treatment of DLBCL with R-CHOP is feasible and can achieve good outcomes in resource-limited settings with rituximab-based chemotherapy. Poor performance status was the most important adverse prognostic factor in this cohort of HIV-negative patients.

Approaches to aggressive B-cell lymphomas in less fit patients

Treating unfit patients with aggressive B-cell lymphoma poses the dilemma of balancing potential cure while minimizing toxicity because of frailty and comorbidities. Age greater than 80 years and common comorbidities such as cardiovascular disease and poorly controlled diabetes mellitus often preclude the use of full-dose anthracyclines and steroids, the backbones of standard regimens for aggressive B-cell lymphomas. Assessing patient fitness remains subjective, with no consensus on best practice or how to integrate assessment tools into decision making. Incorporation of prephase steroids for all unfit patients may markedly improve performance status with consideration of standard dose therapy, especially in patients less than age 80. Although randomized studies are lacking, current data suggest patients age ≥ 80 years are considered unfit a priori and should receive dose-reduced anthracycline regimens or anthracycline-free regimens. Severe toxicity is highest after the first cycle of chemotherapy. Dose reductions for cycle 1 in unfit patients with plans to escalate as tolerated is often an effective strategy. Unfit patients often benefit from comanagement with gerontologists, cardio-oncologists, and endocrinologists depending on age and the nature of comorbidities. Palliative therapy for patients with newly diagnosed aggressive B-cell lymphoma results in median survivals of less than 3 months, and in general, should only be considered in patients with untreatable comorbidities such as advanced dementia or refractory metastatic solid tumors. Incorporating new, potentially less toxic agents such as novel antibodies, antibody-drug conjugates, and bispecific antibodies into first-line therapy is an exciting future direction with potential for substantial benefit in less fit patients.

Improving the international prognostic index score using peripheral blood counts: Results of a large multicenter study involving 520 patients with diffuse large B cell lymphoma

The main purpose of this study was to assess whether it is possible to improve the prognostic impact of international prognostic index (IPI) score by combining it with peripheral blood counts. Thus, we evaluated the prognostic power of lymphocyte, neutrophil, and monocyte counts in 520 patients with diffuse large B cell lymphoma treated with R‐CHOP, confirming that these parameters have a strong impact on overall survival (OS). Using revised IPI (R‐IPI), 44% of patients were categorized as poor‐risk and showed an OS at 5 years of 46%. As OS at 5 years of the 520 patients is 67%, it is clearly evident that R‐IPI tends to overestimate the proportion of patients with poor prognosis. Accordingly, in an attempt to improve the discriminating power of R‐IPI, we evaluated and compared three different scores by combining the neutrophil lymphocyte ratio (NLR) and absolute monocyte count (AMC) with the following values: (a) IPI score 3‐5, (b) age > 60 years and performance status, (c) age  ≥ 65 years and LDH > ULN. The three indexes studied, had a similar 5 years OS for the high‐risk group (46%‐52%), but the proportion of patients classified as poor‐risk were 37%, 20%, and 32%, respectively, which are lower than 44% identified with R‐IPI. Thus, while R‐IPI overestimates the number of high‐risk patients, after applying our models, it is possible to recognize patients who are truly at high‐risk. Of the three scores, the most accurate appears to be that based on NLR, AMC, LDH > ULN and age ≥ 65 years, which identifies 32% of high‐risk patients, correlating well with what is seen in clinical practice.

Is bendamustine-rituximab a reasonable treatment in selected older patients with diffuse large B cell lymphoma? Results from a multicentre, retrospective study

Despite bendamustine-rituximab (BR) showed disappointing efficacy in diffuse large B cell lymphoma (DLBCL), it is still occasionally used as first-line treatment in older DLBCL patients instead of recommended R-CHOP. This multicentre, retrospective study was aimed to clarify circumstances in which BR may be justified in this setting. Patients ≥ 65 years with ECOG performance status (PS) ≥ 2 or ≥ 75 years regardless of PS were included. A total of 140 patients were analysed (BR, 68; R-CHOP, 72). BR patients were older (p < 0.001) and were diagnosed more often with high-risk disease (p = 0.03); no difference regarding comorbidities or PS was seen. Compared with R-CHOP, BR was associated with marked inferior overall survival (OS) (16.3 vs. 75.4 months; p = 0.006) and progression-free survival (PFS) (11.0 vs. 62.3 months; p < 0.001). In multivariate analysis, only high age-adjusted Charlson Comorbidity Index (aaCCI) was associated with inferior PFS in R-CHOP patients (hazard ratio 2.67; p = 0.012). Comparing the subgroup of BR and R-CHOP patients with high aaCCI, there was no difference in OS (p = 0.73) or PFS (p = 0.75). Due to the observed non-superiority of R-CHOP in older DLBCL patients with comorbidities, we propose that this subgroup may be treated alternatively with BR, whereas all other older patients are clearly R-CHOP candidates.

Treatment approaches for older and oldest patients with diffuse large B-cell lymphoma - Use of non-R-CHOP alternative therapies and impact of comorbidities on treatment choices and outcome: A Humedica database retrospective cohort analysis, 2007-2015

INTRODUCTION

We characterized real-world treatment patterns in older (65-74 years) and oldest (75-85 years) patients with diffuse large B-cell lymphoma (DLBCL) receiving initial therapy (R-CHOP, non-R-CHOP regimens). Impact of comorbidities on treatment choice, and overall and progression-free survival (OS, PFS) were assessed by age.

PATIENTS AND METHODS

Using the Humedica database, we identified 1436 newly diagnosed patients with DLBCL who received frontline therapy from 1/07-9/15. The 885 patients ≥65 years of age were further evaluated for baseline demographics, comorbidities, initial therapy, and PFS/OS.

RESULTS

Of 885 patients, 406 (45.9%) were age 65-74, and 479 (54.1%) age 75-85, years. First line therapy was R-CHOP (61.8%) or non-R-CHOP (38.2%). Although Charlson Comorbidity Index (CCI) scores were similar at baseline, congestive heart failure and myocardial infarction were more common in those receiving non-R-CHOP regimens. Survival outcomes were superior for those receiving initial R-CHOP, versus non-R-CHOP, therapy (median PFS 53.9 versus 27.8 months; two-year PFS 71.2% versus 51.6%, p < .0001; median OS not reached versus 45 months; two-year OS 81.3% versus 62.9%, p < .0001, respectively). Only 10.4% (R-CHOP) and 12.1% (non-R-CHOP) of patients received second line therapies. Two-year OS by age (65-74, 75-85 years) was 66.4% and 39.1%, respectively with R-CHOP (p = .0045), and 74.3% and 54.5%, respectively with non-R-CHOP (p = .004), therapy. Age ≥ 75 years and CCI of 2+ were associated with shorter OS and PFS.

CONCLUSIONS

This study identified real-world first line treatment patterns for older patients with DLBCL. Our findings support the feasibility of administering standard R-CHOP therapy, even to oldest patients with DLBCL.

Retrospective analysis of frontline treatment efficacy in elderly patients with diffuse large B-cell lymphoma

OBJECTIVES

To investigate the effectiveness of 2 chemotherapeutic regimens, bendamustine plus rituximab (BR) or reduced-dose cyclophosphamide, doxorubicin, vincristine, and prednisone plus rituximab (RD-R-CHOP), in elderly patients with treatment-naïve diffuse large B-cell lymphoma.

METHODS

A retrospective study was conducted to investigate the efficacy and safety of 2 frontline regimens, BR and RD-R-CHOP, in patients aged ≥75 years unfit for R-CHOP.

RESULTS

From January 2011 to December 2015, 26 patients received BR and 34 RD-R-CHOP. No significant difference was found in clinical background comparisons. The overall response rate was 50% and 79.4% for BR and RD-R-CHOP, respectively (P = .027). Compared with patients in RD-R-CHOP, those in BR had a lower complete remission rate (42.3% vs 70.6%, P = .036), higher progressive disease rate (38.5% vs 8.8%, P = .01), and poorer median overall survival (11.2 months vs 39 months, P = .035). The prognostic difference was mainly observed in patients with limited stage. By contrast, BR had better toxic profiles. Some patients in BR certainly showed long-term survivals.

CONCLUSIONS

This study demonstrated better efficacy of RD-R-CHOP, indicating its administration might be considered whenever possible, especially for limited stage. However, BR is a reasonable alternative for those ineligible for anthracycline-containing regimens. Further studies are needed to guide treatment decisions.

Role of anthracycline and comprehensive geriatric assessment for elderly patients with diffuse large B-cell lymphoma

Survival outcome for elderly patients with newly diagnosed diffuse large B-cell lymphoma remains suboptimal in the rituximab era. In this systematic review, we summarize available evidence relevant to the inclusion of anthracycline in upfront chemoimmunotherapy for these elderly patients and highlight the need of prospective clinical trials. With limited prospective data, we find that pretreatment comprehensive geriatric assessment accurately predicts survival and treatment-related toxicities, suggesting its potential role in guiding overall treatment decision-making.